Alden Lakeland Rehab & Hcc

Based on observations, interviews and record reviews, the facility failed to have adequate staffing to ensure two (R4, R5) out of eight residents reviewed for ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all residents residing on the second floor and third floors. On 1/27/26 at 8:15 AM, V30 [R3's Family Member] stated, On 12/25/25 around 5PM, I noticed the nurse earlier was not there. A certified nurse assistant reported the nurse from 7AM to 3PM was gone and there was one nurse on the other side. I walked to the other end of the third floor and spoke to V33 [Registered Nurse]. V33 reported the 3PM to 11PM nurse called off. V33 said she was not liable for all fifty residents on the entire floor. I went to the front desk and asked V36 [Facility Receptionist] to call the administrator [V1]. I heard V36 explain to V1 my concerns, V36 replied V1 would get coverage. There is always a staffing issue at the facility. There were several times R3's under brief was entirely wet and soiled with feces stuck to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to a.) ensure two (R8, R9) resident's oxygen was on the correct setting b.) failed to ensure respiratory equipment was labeled and stored to prevent contamination for two (R8, R9) residents and c.) failed to ensure one (R13) resident had a physician order for oxygen. These failures have the potential to affect 5 residents reviewed for oxygen use.Findings Include: R8 has diagnosis not limited to Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Respiratory Failure with Hypoxia, Bipolar Disorder, Specified Depressive Episodes, Dependence on Supplemental Oxygen and Pulmonary Hypertension. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R8's Care Plan document in part: Focus: R8 is at risk for falls due to weakness, Respiratory failure, dependency on oxygen and asthma. Focus: R8 has potential for shortness of breath, anxiety and/or fatigue due to COPD that require…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident (R3) received scheduled blood thinner medication as ordered by a Physician. This failure has affected one of three residents reviewed for medication. Findings include:R3 is a [AGE] year old with diagnosis including but not limited to: Aftercare following joint replacement surgery, presence of artificial hip joint, polyosteoarthritis, long term use of anticoagulants and abnormalities of gait and mobility.R3 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.On 12/24/25 at 9:23 am R3 stated the following, I went four days without receiving my blood thinner medication in the facility. I had asked about my blood thinner and one of the nurses told me that they were waiting for the medication to be delivered from the pharmacy. I had to continuously ask about the blood thinner because I was concerned about getting a blood clot and understand the importance of receiving my blood thinner.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to update interventions on the care plans of residents who experienced falls. This applied to two residents (R8 and R9) out of 9 residents reviewed for falls. Findings Include:On 11/18/2025 at 11:00 AM, there were floor mats observed on both sides of R8's bed. There was also a large floormat on the wall to the right to R8's bed. R8 was not in the room at the time of this observation. During same time, R9 was in R9's bed, lying on R9's back in an upward straight position. R9 was calm, quiet and responsive indicated by eye movements and facial expressions. There were floormats to the right of bed and short rails. R8 and R9 share the same room.On 11/18/2025 at 11:11 AM, R8 was in the dining room with V10 (Certified Nursing Assistant (CNA)) and a visitor. R8 then became very active throughout his body in jerking motions and began to kick rapidly upon the presence of the surveyors. R8 also observed to have wounds on the lower legs. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to get one resident (R2) out of bed as requested and failed to ensure call light was within reach for two residents (R2, R5).Findings include: On 08/26/2025 at 11:25 AM, observed R2 lying in bed wearing street clothes. V5 (Certified Nursing Assistant) had mechanical lift outside R2's door and was getting ready to transfer R2 out of bed into his motorized wheelchair but said she had to find another staff member to help her. There was no call light within R2's reach. Call light switch was in the up position on the wall with no string attached to the switch. R2 stated he does not have a personal phone. On 08/26/25 at 11:30 AM, R2 stated he likes to get out of bed around lunch time and then likes to go out on pass into the community using his motorized wheelchair. R2 stated on 08/18/25 he was never taken out of bed; he spent the entire day in his bed. R2 stated V10 (Certified Nursing Assistant) assigned to him that day got him dressed after lunch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation, interview and record review, the facility failed to ensure the Low Air Loss Mattress was set at the recommended setting and failed to ensure the Low Air Loss Mattresses were not layered with multiple linens. These failures affected 4 residents (R73, R116, R125, and 144) reviewed for prevention and treatment of pressure injury/ulcer in the sample of 61 residents. Findings include: R73's admission record diagnoses include but not limited to quadriplegia, chronic respiratory failure, tracheostomy, gastrostomy, pressure ulcer of sacral stage 4, pressure ulcer of right upper back, pressure ulcer of right heel, cirrhosis of liver, hepatitis, and neuromuscular dysfunction of bladder. R73's (2/7/25) Brief Interview of Mental Status (BIMS) score is blank. R73's cognitive skills for daily decision making are severely impaired. On 5/12/25 at 10:40 am, R73 was lying on a low air loss mattress with multiple layers between R73 and the low air loss mattress. The layers observed under R73 consisted of a flat sheet, a mattress pad, and an incontinent brief. R73's POS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe storage of compressed oxygen tanks in a holder (carrier). This failure has the potential to cause fire, explosive, or projectile hazards. This failure affected 2 residents (R54 and R503) and has the potential to affect all residents on the second and fourth floor in a sample of 98. Findings Include: R503's face sheet dated May 13, 2025, documents in part a diagnosis of Acute Respiratory Failure with Hypoxia, Interstitial Pulmonary Disease, Pulmonary Fibrosis, Seizure Disorder, Hypertension, and Dementia. On 5/12/2025 at 12:14 am, R503's compressed oxygen tank was observed sitting on the floor not contained in a holder (carrier) in front of R503's bed against the wall. On 5/12/2025 at 12:18, V12, (Licensed Practical Nurse-LPN) stated Oxygen tanks do not have to be stored in a holder when the tank is in the room. V12 stated oxygen tanks are only in an oxygen tank holder when residents are being transported to therapy or services. V12 removed the oxygen tank from the room. On 5/14/2025 at 10:04 am,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow prescribed physician Oxygen Therapy Orders for 4 residents (R101, R202, R502, R503), failed to ensure the humidifier bottle was changed per facility policy for 1 resident (R18) and failed to ensure (R3's) BiPap mask and (R66's) canister tubing was contained in a bag while not in use. These failures affected 7 residents (R3, R18, R66, R101, R202, R502, R503) in the sample of 61 residents. Findings Include: On 5/12/2025 at 11:23am, R101 was observed in bed alert and oriented to person, place, time, and situation sitting in bed. R101's continuous oxygen was set at 2 liters per minute. On 5/12/2025 at 11:28am V11, (Registered Nurse-RN) stated R101 is on continuous oxygen 3 liters per minute. V11 stated the purpose of oxygen therapy is to prevent shortness of breath. V11 stated a resident can desaturate and have breathing problems or shortness of breath is the oxygen is not set as prescribed. R101's Face Sheet documents in part a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect all 24 residents receiving medications from the 3rd Floor Vent Team #1 medication cart. The facility also failed to ensure the tablet count documented on the controlled drug receipt/record/disposition form matched the number of tablets contained in the medication bubble pack. The counts should match to prevent the loss and/or diversion of controlled substances. This failure had the potential to affect all 19 residents who receive medications from the 2nd floor LTC (long-term care) medication cart. Findings include: On 05/13/2025 at 12:50pm observed the controlled substance binder and controlled substance bubble packs/medication cards for the 2nd floor LTC medication cart with V25 (RN/Registered Nurse). Observed a bubble pack of controlled substance which contained seven tablets; observed the controlled drug receipt/record/disposition form for the bubble pack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure that bottles of medication in the medication cart which are specifically prescribed for a resident and not considered a stock medication were properly labeled with the resident's information and expired medications were removed from the shelves used to store stock medications in the medication storage room. This deficient practice has the potential to affect 19 residents who receive their medications from the 2nd floor medication cart and 58 residents on the 3rd floor who may receive stock medications from the 3rd floor medication storage room. Findings include: On 5/13/2025 at 12:40pm, inspected the 2nd floor LTC medication cart with V25 (RN/Registered Nurse). The following was observed, 2 bottles of Velphoro 500mg (milligram) tablets were not labeled with a resident's name or directions for use. On 5/13/2025 at 12:45pm V25 (RN/Registered Nurse) stated these two bottles are not stock medication, this medication is for a specific resident. V25 stated the medication should be labeled with the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews, the facility failed to discard expired food items from the dry storage area of the facility's kitchen and failed to label frozen food items in the freezer with an open date. These failures could potentially affect 113 residents consuming the facility's food out of 155 residents residing at the facility. Findings include: On 5/12/2025 at 09:34 AM, V1(Administrator) provided facility's current resident's census that showed a total of 155 residents. On 5/12/2025 at 11:00 AM, the facility provided a Diet Type Report of residents which showed a total of 42 residents with a nothing by mouth (NPO) diet. On 5/12/2025 at 09:35 AM, observed in the facility's kitchen freezer, five opened containers of 3-gallon size multiflavored ice scream, no open date. (Two containers of Vanilla, one container of Strawberry, one container of Mint Chip and one container of Chocolate flavor). V3 (Corporate Dietary Coordinator), stated, that the open ice scream containers should be dated when opened and when received. V3 also stated that the opened, unmarked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure midline catheter dressings were changed for 2 (R23 and R132) residents, failed to ensure staff don appropriate PPE (personal protective equipment) during transfer for 1 (R20) resident, and failed to ensure tube feeding equipment used for a resident (R81) on EBP (enhanced barrier precautions) were stored appropriately. These failures affected 4 (R20, R23, R81, and R132) residents and has the potential to affect all the residents on the 3rd floor. Findings include: The (05/12/2025) 3rd floor census was 62. On 05/12/2025 at 10:40am, there was a half wall divider with railing in the dining/activity area. There was a container with piston irrigation syringe on top of the half wall. The container was labeled with R81's name, R81's room, and the current date. R60, R61, and R89 were seated close to the half wall divider. This observation was pointed out to V11 (Registered Nurse). V11 checked the label on the container of the piston…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's piston syringe and its container which was labeled with the name and room number of a resident, was kept inside the resident's room. This failure affected 1 (R81) resident reviewed for privacy and dignity in the total sample of 61 residents. Findings include: The (undated) Get Up List For Dining And Activities listed 7 residents on 3rd floor. On 05/12/2025 at 10:40am , there was a half wall divider with railing in the dining/activity area. A container with piston irrigation syringe was on top of the half wall. The container was labeled with R81's name, R81's room, and the current date. R60, R61, and R89 were seated close to the half wall. This observation was pointed out to V11 (Registered Nurse). V11 checked the label on the container of the piston irrigation syringe and stated it has (R81)'s name and room number and today's date. We use it for feeding tube. I don't know why these are here in the dining area. These should be in the resident's room for the privacy and dignity of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure the call light device was within reach for two residents (R42, R203). This failure affected R42 and R203 in the sample size of 61. Findings include: R203 has a diagnosis of but not limited to Fracture of Lower End of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, End Stage Renal Disease, Dependence on Renal Dialysis, Hemiplegia and Hemiparesis Following Cerebral, Infarction Affecting Right Dominant Side, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. R203 has a Brief Interview of Mental Status score of 05, but resident responded to surveyor's questions appropriately. Care plan focus for falls dated 5/07/2025 documents, in part, encourage resident to call, don't fall and promote placement of call light within reach. On 5/12/2025 at 11:40am R203's call light cord was hanging down to the floor behind the bed and not within reach of resident. Findings include: On 05/12/2025 at 11:27am, R42's call light was on the nightstand, not within R42's reach. R42 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and document the code status in the resident's electronic medical record for one resident (R132) reviewed for advanced directives in the sample of 61 residents. Findings Include: R132's admission Record documents, in part, diagnoses of chronic respiratory failure, anoxic brain damage, type 2 diabetes mellitus, dependence of respiratory, and a blank space is noted under R132's Advance Directive section of the profile screen (admission Record). R132's Minimum Data Set (MDS) dated [DATE] has a Cognitive Skills for Daily Decision Making Score of 3, which indicate R132's cognition is severely impaired. R132's Order Summary Report with active orders as of 05/13/25, documents that no physician's order for advance directives (full code or DNR status) for R132. On 05/13/25 at 10:21am V2 (Director of Nursing/DON) stated that a resident's code status should be entered on admission. V2 stated that the resident's code status can be found on the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a homelike environment by not supplying a resident (R36) with a television, personal light source and not assisting with putting away personal belongings. This failure affected one resident (R36) reviewed in the final sample of 61 residents. Findings include: Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. On 5/12/2025 at 12:24 PM observed R36's room without a television or a night lamp. Also observed in the resident's room, a dresser in a corner of the room with a suitcase positioned on the top. The dresser was positioned with the drawers facing the wall, away from resident's reach. Resident was not in the room at the time of observation. On 5/12/2025 at 12:24 PM, V30, (Licensed Practical Nurse/LPN), stated that R36 is out on pass and should return to facility later. On 5/13/2025 at 12:47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Observation, interview, and record review, the facility failed to thoroughly implement communication/translation interventions for this resident on the individualized care plan. This failure affected one resident (R111) reviewed for Alternative communication/translation interventions in a sample of 61 residents. Findings include: On 05/12/25 at 11:57 AM, R111 was observed in the bed during interview, R111 stated he needed a Spanish translator to assist with communication because he (R111) spoke very little English. There was no communication board or communication contact number observed in R111's room at time of interview. V16 and V17, certified nursing assistants (CNAs), were in the room but neither were able to communicate with R111 because of the language barrier. On 05/12/25 at 11:59 AM, V16 (CNA), stated she normally tries to figure out what R111 is saying by gestures but R111 becomes frustrated at times because his (R111) needs aren't met because of the language barrier. On 05/12/25 at 12:00 PM, V17 (CNA), stated she stated she does not speak Spanish and tries her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that a restorative rehabilitation program was being thoroughly implemented for a resident (R53) as documented in the plan of care. This failure affected one resident (R53) reviewed for Restorative Nursing program in a sample of 61 residents. Findings include: R53's Face sheet dated May 14, 2025, documents in part that R53 was admitted to facility on June 24, 2024 with diagnosis including End stage renal disease, hypertensive chronic kidney disease, diabetes mellitus, anemia, hyperlipidemia, diverticulosis, morbid obesity, glaucoma, muscle weakness. R53's MDS (Minimum Data Set) dated March 13,2025 section C, shows R53 has a score 15 of which means R53 is cognitively intact; section GG Functional abilities, shows R53 has a score of 2 which means R53 requires substantial/maximal assistance for care. R53's care plan dated June 12,2024 shows that R53 has limitation in range of motion due to weakness and pain. Interventions/Tasks: Staff to provide active range of motion to R53, exercises to bilateral upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide immediate intervention for a resident (R36), complaining of unrelieved pain on reassessment. This failure affected one resident (R36) of the total sample of 61 residents. Findings include: Face sheet documents R36 was transferred from acute care hospital to the facility on 4/16/2025 with the diagnosis included but not limited to Other Systemic Sclerosis, Other Venous Thrombosis and Embolism, Acquired Absence of Other Right Toe, and Lymphedema. Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. On 5/13/2025 at 12:47 PM, observed R36 in the room, sitting on the side of the bed with both legs touching the floor, with body tilted to the side. Both feet and legs were swollen, the right foot had a contracture of the toes and a missing toe. Resident was alert and oriented and well dressed. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon interview and record review the facility failed to follow policy procedures, failed to notify the physician and/or family of abnormal diagnostic test results, and failed to provide accurate information to one of four residents (R2) reviewed for change in condition. Findings include: On 4/28/25, IDPH (Illinois Department of Public Health) received allegations that R2 was found to have blood clots of leg and the Physician waited 2 days to read the ultrasound. R2's face sheet includes two (2) emergency contacts and phone numbers. R2's (2/15/25) progress note states writer noted unilateral swelling on the leg, warm to touch and capillary refill at 3 seconds. Resident complained of pain. Writer notified provider with other (typo) for venous and arterial doppler. Order noted and carried out [family notification was excluded]. R2's (2/18/25) right lower extremity (arterial) duplex scan (reported 2/18/25) affirms mild to moderate peripheral arterial disease. Advised clinical correlation and follow-up as indicated. R2's (2/18/25) right lower extremity (venous) duplex scan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a resident with transportation arrangements to and from a CT (computed tomography) scan, resulting in the resident missing multiple appointments and experiencing a delay in treatment for one (R3) resident out of three residents reviewed for resident rights in a total sample of five. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Findings include: On 4/16/2025, at 11:51 AM, V10 (Medical records/Transportation coordinator) states I come on a Monday. I run the report and see what appointments I have that week, or sometimes I review it on Friday to see for the next week. V10 states when we were using the ride-hailing service, it was easier. But now since I am back calling the insurance, I must check them beforehand since I must let them know at least 3 days in advance. V10 states facility ride-hailing service card ran out/declined on April…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and investigate a sexual abuse allegation for one (R14) of four residents reviewed for abuse in a total sample of 30. Findings include: On 03/27/2025, 9:40 AM, V32 (Social Services Director) states I did the discharge for R14. She was discharged on March 10th, 2025. It was requested by her guardian to be transferred to a different facility. Her guardian had come the week prior to check on her, and he said everything was fine. She was a bit confused. He just spoke to his team and he wanted her in a different facility. I'm not sure exactly why the request was made. V32 states my boss asked me to transfer her out, since he is the guardian, we follow his wishes. V32 states that R14's case manager was made aware of an allegation that was made regarding R14. V32 states that she informed R14's case manager that it wasn't witnessed by staff, it was witnessed by a family member. According to the family member, the other resident put his hands on R14's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform urinary catheter care in a manner that would prevent a urinary tract infection/UTI. This failure affects one (R24) resident out of three residents reviewed for urinary catheter care in a total sample of 30 residents. Findings include: R24's facesheet documents that R24 was admitted to the facility on [DATE]. R24's facesheet documents that R24 has diagnoses not limited to: anoxic brain damage, quadriplegia, chronic respiratory failure, urinary tract infection, infection and inflammatory reaction due to indwelling urethral catheter, dysphagia, and bacteremia. On 03/26/2025, at 2:33 PM, R24 observed lying in bed with a gown on. G-tube (gastronomy tube) and tracheostomy were in place. The head of bed at 45 degrees. R24's urinary catheter observed intact and draining urine via gravity into a drainage bag. R24's drainage bag observed with 1100 milliliters of urine inside. R24 is not alert or oriented and is unable to make his needs known. R24's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow policy and obtain a consent from a resident's representative for a psychotropic medication dosage increase. This failure affected 1 resident (R5) out of 5 residents reviewed for psychotropic medications in a total sample of 30 residents. Findings include: R5's face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Dysphagia following cerebral infarction, aphasia following cerebral infarction, other sequelae of cerebral infarction, chronic respiratory failure, encounter for attention to tracheostomy, type 2 diabetes with diabetic chronic kidney disease, history of falling, adjustment disorder. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R5 is severely impaired. Care plan (dated 01/29/2025) documents that R5 has the potential for pain related to presence of tracheostomy, vent dependence, and presence of G/tube. Also, R5 has hemiplegia due to CVA (cerebrovascular accident/stroke)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to keep one (R5) of 3 residents free from the risk of communicable disease transmission of 30 reviewed for infection control. Findings include: 3/26/25, at 11:40 AM, writer observed R5 cohorted in room with R26. 3/26/25, at 1:42 PM, V12 (Licensed Practical Nurse) stated a resident with MDRO (multidrug resistant organism) and C. Auris (Candida auris) would not be in a room with a resident that does not have the same. To my knowledge R26 does not have anything to contaminate R5. 3/26/25, at 2:18 PM, V16 (Registered Nurse) stated a resident with MDRO and C. Auris needs to be on contact isolation and have to be roomed with someone with the same strain. If I see where residents cannot be roomed together due to infection, I will notify admissions, the Director of Nursing, and manager. Residents are cohorted according to the same organism. A resident with a microorganism is not roomed with a resident without a microorganism. 3/27/25, at 1:10 PM, V2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their own policy of initiating a fingerprint based criminal history records check of an employee in an effort to prevent abuse at the facility. This failure has the potential to affect all the residents residing on the 3rd floor Vent Unit. Findings include: The (02/18/2025) email correspondence with V2 (Director of Nursing) upon request of V28's (Certified Nursing Assistant) floor assignment documented, in part Her floor assignment is Vent on 3rd floor. The (02/09/2025) daily census on 3rd floor Vent Unit was 33. On 02/11/2025 at 9:52am, V24 (Business Office Manager/HR Manager) stated the purpose of conducting background check is to ensure who we are hiring are people who do not have anything in their background like criminal situation such as theft, murder, abuse like physical, mental, verbal, misappropriation of finances, sexual, and neglect. I do the background checking after interviewing prospective employee and before hire. On 02/11/2025 at 9:54am, during the review of V28 (Certified Nursing Assistant) employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure dietary recommendations for residents on feeding tube were ordered and carried out timely for 5 (R1, R14, R15, R16, and R17) residents reviewed for tube feeding in the total sample of 17 residents. Findings include: The (01/16/2025 - 01/16/2025) General Notes Report documented, in part (R1) - Note type: Dietary Recommendations. Rec (recommended) to adjust TF (tube feeding) to Diabetisource AC to infuse 1350cc/day @75cc/hr + 175CC/HR H2O (water) Flush Q (every) 4HR. (hour) Created By/Revised By: V8 (Dietitian). (R14) - Note type: Dietary Recommendations. Rec (recommend) to adjust TF (tube feeding) to Novasource Renal to infuse 1000cc/day @ 80cc/hr to start at 6pm, please notice time change and rate change. Created By/Revised By: V8. (R15) Note type: Dietary Recommendations. Rec to increase rate of TF to Diabetisource AC to infuse 1200cc/day@ 80cc/hr. (R1) Note type: Dietary Recommendations. Rec to adjust TF to Diabetisource AC to infuse 1350cc/day @75cc/hr + 175cc H20 (water) flush q (every) 4 HR. vit C for tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one dependent resident (R3) was properly dressed when going out into the community. This failure has affected one of three residents reviewed for resident's rights. Findings include: R3 is a [AGE] year old with diagnosis including but not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side, polyosteoarthritis, generalized edema, muscle weakness, chronic pain and cognitive communication deficit. R3 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 2/10/25 during investigation at 11:18 AM, R3 said, I went out for my dental appointment about two weeks ago with my gown, jacket and a hat on. The staff didn't know about my appointment until the last minute. I was in the dining room about to have lunch, when my CNA (Certified Nurse Assistant) came and got me to take me to my room and put a purple jacket on top of my gown. I was freezing. It was about 10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure agency staff had adequate competency, training and the skills necessary to care for the facility's residents. This failure has the potential to affect all residents that reside within the facility. Findings include: Record review of active resident census documents that 162 residents reside within the facility. On 1/27/2025 at 1:29 PM, V20 (Agency Registered Nurse) stated that V20 has picked up shifts on 2 occasions at the facility but couldn't recall if V20 had worked on 1/8/2025 when R1 was readmitted . V20 stated, go look in the chart, and see if I worked. You see my notes? Then clearly I worked. V20 stated that V20 recalled getting an admission on one of the shifts. V20 explained that V20 transcribed the orders and called the nurse practitioner, and no orders were changed from the discharge paperwork. Surveyor reviewed the discharge paperwork with V20 and V20 affirmed that those orders for metronidazole and vancomycin should have been transcribed. Surveyor asked where V20 transcribed the orders to and V20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an accurate facility assessment that includes staffing information that identifies staffing needs per shift/unit; identifies respiratory therapists within the staffing plan; identifies the contracts to staff respiratory therapy staff. This failure has the potential to affect all residents that reside within the facility. Findings include: Record review of active resident census documents that 162 residents reside within the facility. Record review of facility assessment dated [DATE], documents in part the following: 1) The number of residents the facility is licensed to care for broken down by floor/unit, however only floors are specified. The ventilator unit is not identified. 2) Respiratory therapists are not identified as a staff member needed to care for the facility's population. 3) Staffing plan lists total number of FTE (full-time employees) needed for the facility. The staffing plan does not indicate how many staff and what kind of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement the facility's plan of correction for survey compliance by fully and accurately completing the quality assurance (QA) audit tools which has the potential to affect the 148 residents residing in the facility when reviewed for quality assurance and improvement activities. Findings include: A) Facility document titled Plan of Correction and Allegation of Compliance with completion date listed as 2/1/2025, documents, in part, for F880 that the actions taken to identify other resident that may have the potential to be affected by the same practice: The facility made observations of residents on utilizing indwelling (catheters), and the Quality Assurance plans to monitor facility performance to make sure corrections are achieved. A QA Tool was developed for ensuring indwelling catheter tubing does not touch the floor. This will be initiated by the Director of Nursing or designee. This QA Tool will be completed three times per week for 30 days, weekly for 30 days, monthly and then on an as needed basis. A QA Tool was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure foley catheter tubing was off the floor; failed to follow the infection prevention policy and complete data collection/surveillance related to infections. This failure has the potential to affect all residents that reside within the facility. Findings include: Record review of active resident census documents that 162 residents reside within the facility. On 1/24/2025 at 12:51 PM, V3 (Infection Preventionist, Licensed Practical Nurse) affirmed that V3 is the infection preventionist for the facility. V3 provided a copy of the facility's infection control log. Surveyor completed review of infection control log with V3 and noted that the infection control log was missing R1's cases of pneumonia, types of pathogens were not being tracked, symptoms were not being tracked, and mapping of infections was not completed. V3 stated, I (V3) do not have to track all that (pathogens, symptoms, mapping). I only have to track antibiotics. If someone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oral care is being provided to residents on the ventilator unit in a manner that meets professional standards; failed to administer oral care in accordance to facility policy. This failure affects 1 resident (R2) and all 36 residents that reside on the ventilator unit. Findings include: Record review of R2's Minimum Data Set, dated (11/7/2024) documents in part that R2 is dependent on facility staff for oral care. On 1/24/25 at 10:00 AM, surveyor observed R2 with thick, beige secretions covering R2's lips and teeth. V8 (Agency Certified Nursing Assistant) observed R2 and stated that R2 was in need of oral care but that V8 provided it earlier today. On 1/24/25 at 10:03 AM, V9 (Licensed Practical Nurse) entered the room and observed R2. V9 affirmed that R2 needed oral care and addressed V8 stating, I (V9) told you earlier that he needed oral care, why didn't you do it? V8 replied, I (V8) did it earlier, (R2) is just having a lot of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure the final investigation report was submitted for neglect to the state survey agency within 5 business days of the initial report being submitted. This failure affects 1 resident (R8) reviewed for reporting. Findings include: On 3/5/2025 at about 10:30am surveyor requested IDPH reportables from 1/30/2025-present from V1(Administrator). On 3/5/2025 and 3/06/2025 surveyor requested, on several occasions, the IDPH reportables from 1/30/2025-present from V1 and they were not provided. On 3/6/2025 at 11:39am V20 (Nurse Consultant) stated the final investigation report was not submitted to IDPH, five days after the initial report was reported, because the Plan of Correction had been submitted in its' place. On 3/6/2025 at about 11:41pm V1 (Administrator) provided surveyor with the initial Incident/Accident Notification Initial Report dated 1/25/2025 that documents, in part, this will serve as an initial report. Investigation initiated and final report to follow. There was no final report provided. On 3/6/2025 at 2:45pm V1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to perform a thorough investigation into a neglect allegation and submit the findings to state survey agency within 5 business days of the initial report being submitted. This failure affects 1 resident (R8) in a sample size of 8. Findings include: On 3/5/2025 at about 10:30am surveyor requested IDPH reportables from 1/30/2025-present from V1(Administrator). On 3/5/2025 and 3/06/2025 surveyor requested, on several occasions, the IDPH reportables from 1/30/2025-present from V1 (Administrator) and they were not provided. On 3/6/2025 at 11:39am V20 (Nurse Consultant) provided surveyor with the initial investigation for the 01/25/2025 reportable and replied, the final investigation report was not submitted to IDPH, five days after the initial report was reported, because the Plan of Correction was submitted in its' place. On 3/06/2025 at 2:45pm V1 stated the final report should be submitted within 5 days of the initial report to IDPH but in this case, the final report was not submitted because I considered our POC (Plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation interview and record review, the facility failed to ensure nebulizer tubing was changed per facility policy. This failure has the potential to affect 1 resident (R12) sampled for respiratory care. Findings include: Record review of R12's Minimum Data Set (dated 12/23/2024) documents in part that R12 is unable to speak, is rarely/never understood, is cognitively impaired, is dependent on staff for activities of daily living, and utilizes a ventilator. On 1/27/2025 at 11:44 AM, R12 was observed lying in bed with nebulizer tubing attached to R12's tracheostomy site. V10 (Resident Care Coordinator, Licensed Practical Nurse) observed the nebulizer tubing for R12 and affirmed it was dated 1/15/2025. V10 stated the nebulizer tubing should be changed weekly to prevent infection. Record review of R12's progress notes for 1/29/2025 document that R12 was diagnosed with a urinary tract infection, pneumonia, and sepsis. Record review of facility policy titled, RESPIRATORY EQUIPMENT CHANGE PROCEDURE (10/2018) documents in part, .4. Nebulizer set-ups for bronchodilator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to follow their policy to ensure that call lights are answered in a timely manner to five (R4, R10, R17, R18, & R19) residents out of 7 residents reviewed for call light. Findings Include: R4's face sheet shows R4 is a [AGE] year-old male. R1's health record documented admission dated 10/26/23 with diagnoses not limited to paraplegia unspecified, neuromuscular dysfunction of bladder, muscle weakness, unspecified lack of coordination, pressure ulcer of sacral region stage 4, and pulmonary embolism with acute pulmonale. On 1/7/25 at 11:01 AM, R4 received up in motorized wheelchair clean and well groomed. R4 stated that R4 has been in the facility for sixteen months, and R4 stated that most of the times, R4's call light will be on for an hour before staff will respond. R4 stated that R4 sits on soiled linen for too long, and that afternoon (PM) shift does not respond to call lights. On 1/8/25 at 10:16 AM, V21(Certified Nursing Assistant/CNA) stated that all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure enhanced barrier precaution signage were posted on residents' (R6, R7, R8) doors and failed to ensure proper personal protective equipment (PPE) were used during high contact resident care activities for 4 residents (R1, R6, R7, R15). These failures have the potential to affect all 65 residents residing on the third-floor unit. The facility also failed to ensure a resident (R5) with MDRO (Multidrug-Resistant Organism) was appropriately cohorted in a room with another resident. This failure affected 1 (R10) out of 1 resident in a sample of 14 residents reviewed for infection control. Findings Include: 1) On 1/07/25 at approximately 9:41 AM, Surveyor and V3 (Certified Nursing Assistant/CNA) entered R6's room. R6's door/room had no transmission-based precaution signage. R6's enteral feeding as running. R6 was non-verbal. Surveyor asked V3 to assist in checking R6's gastrostomy tube (G-tube) site. V3 did not wear an isolation gown when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure in notifying resident representative of a cognitively impaired resident prior to changing the resident's room. This failure affected one (R5) out of 5 residents sample reviewed for resident rights. Findings Include: R5's clinical records show an initial admission date of 11/03/17 with included diagnoses but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia, and Encounter for Attention to Cystostomy. R5's Minimum Data Set (MDS) dated [DATE] shows R5 has severely impaired cognition. R5's census list report printed on 1/07/25 shows R5 was transferred to a different room on the 4th floor on 12/17/24 and then to a different room on the 3rd floor on 12/18/24. A review of R5's electronic health records and progress notes dated 12/01/24 to 12/25/24 show no documentation that R5's representative was notified of R5's room changes. On 1/07/25 at 12:24 PM, V2 (Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain a physician's order for splint use and to develop a compressive care plan for one (R1) resident out of two residents reviewed for splint use. Findings Include: R1's face sheet shows R1 is a [AGE] year-old male. Minimum Data Set, dated [DATE] shows R1 is cognitively severely impaired with functional limitation in range of motion in all extremities. R1's health record documented admission dated 05/17/24 with diagnoses not limited to anoxic brain damage, chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, chronic kidney disease with heart failure, encounter for attention to tracheostomy, poisoning by heroin, chronic obstructive pulmonary disease, ventilator associated pneumonia, encounter for attention to gastrostomy, unspecified dementia, and sepsis unspecified organism. On 1/7/25 at 10:30 AM, R1 received up in recliner chair in the day room, alert and not verbal. On 1/8/25 at 9:36 AM, R1 received in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their own policy of reporting injury of unknown origin within the timeframe. This failure affected 1 (R3) resident reviewed for incident and accident in the total sample of 5 residents. Findings include: On 10/23/2024 at 10:48am, V13 (Wound Care Coordinator) stated R3's scar is about 2cm x 0.5cm, (centimeter) vertically above the left side of the upper lip. On 10/22/2024 at 2:59pm, V4 (Licensed Practice Nurse) stated it was in the afternoon on second shift when it happened. I (V4) walked my CNA (V8 -Agency CNA) to do the rounds He (R3) was fine. I (V4) gave him (R3) his med at 4pm and he was ok. Then V9 (Nurse Practitioner) walked into the room and went back out, and said do you know (R3) was bleeding. On 10/22/2024 at 3:18pm, V4 stated I notified the doctor, family, V2 (Director of Nursing) and V3(Assistant Director of Nursing). I (V4) told V2 that R3 has an open area on his left upper lip. I (V4) called R3's family and I (V4) told them I could not explain how it happened and that (V2) would get back to them. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure the low air loss mattresses were set on the recommended settings. This failure affected 2 (R3 and R5) residents reviewed for the treatment of pressure injury in the total sample of 5 residents. Findings include: On 10/22/2024 at 11:16am V10 (Certified Nursing Assistant) went inside R5's room. R5 was lying on low air loss mattress. Setting was at 340lbs. (pounds), alternating every 10 minutes. This surveyor requested V10 to check R5's low air loss mattress setting, and stated setting is at 340lbs, alternating every 10 minutes. R5 stated I weigh 247lbs. On 10/22/2024 at 11:37am, R3 was lying on a low air loss mattress, setting at 280lbs alternating every 10 minutes seat inflate. This surveyor requested V4 (Licensed Practice Nurse) to check R3's low air loss mattress setting and stated his (R3) low air loss mattress is set at 280lbs, alternating every 10 minutes. This surveyor inquired how much R3 weighs. V4 stated I need to check his record. On 10/22/2024 at 11:40am, V4 stated he weighed 197.4lbs on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that five resident (R10, R65, R86, R99 and R102) who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving and nail care. This failure affected four out of 62 residents reviewed for ADL care. Findings include: R86's Brief Interview for Mental Status (BIMS) dated 04/23/24 shows that R86 has a BIMS score of 15 which indicates that R86 is cognitively intact. R86 has a diagnosis which includes but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, essential primary hypertension, muscle spasm, and type 2 diabetes mellitus without complications. R102's Brief Interview for Mental Status (BIMS) dated 05/08/24 shows no BIMS score for R102. During Surveyors interview with R102, R102 was alert and oriented and able to answer questions appropriately. R102 has a diagnosis which includes but not limited to: paroxysmal atrial fibrillation, hypertensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 07/09/24 at 11:35 AM, Surveyor observed R105 asleep in bed and R105's low air loss mattress set to 280 lbs., alarming with 01 error code. V16 (Wound Care Coordinator, Licensed Practical Nurse) confirmed R105's low air loss mattress settings and affirmed resident did not weigh 280 lbs. V16 then changed the settings to 200 lbs. Record review with V16 confirmed R105 last weight is 203 lbs. V16 stated that V16 did not know what the error code meant, but that V16 would submit a request for maintenance. V16 affirmed that if low air loss mattresses are not set to the right weight, it may not achieve adequate pressure relief. R105's admission record documents in part the following diagnosis: heart failure, type 2 diabetes with foot ulcer, peripheral vascular disease, pressure ulcer of sacral region stage 3, pressure ulcer of left buttock stage 3, pressure ulcer of right ankle unstageable, pressure ulcer of right heel unspecified, non-pressure chronic ulcer of other part of right food with necrosis of muscle. R105's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that staff use proper hand hygiene and sanitary conditions when performing resident care and wound care for three residents (R69, R84 and R103); failed to perform hand hygiene prior to plating resident's meals from steam table; failed to properly don PPE (Personal Protective Equipment) for three residents (R52, R55, R69 and R132) who required EBP (Enhanced Barrier Precautions). This deficient practice has the ability to affect all 67 residents on the 3rd floor. Findings include: On 07/09/24 at 10:40 AM, V20 (Licensed Practical Nurse, LPN) observed pushing wound treatment cart through hall with V20's hands, and V20 parked treatment cart outside R103's room. V20 (LPN) removed 4 inches by 4 inches (4x4) gauze from open, bulk package of gauzes inside drawer of wound cart using V20's bare hands and without sanitizing hands. V20 (LPN) stated, I sanitized my hands down there when I left out the other room, you just didn't see me. V20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that call light systems were operating in good working condition. This failure affected 5 residents (R143, R61, R114, R31, R67) in a sample of 62. Findings include: 1. On 7/8/2024 at 11:05 AM, R143 expressed that R143's call light was not working. R143 stated that not having a way to call for assistance gives R143 anxiety and has had to often call the facility using R143's personal cell phone because the call light does not work. Surveyor observed the following: call light system in resident room consisting of a flip toggle switch ([NAME] to light switch) with a hole in the center of the switch on the wall of the room. A neon yellow string was tied in a knot to R105's (R143's roommate) call light string about half-way down R105's call light string. Surveyor asked R143 to demonstrate call light use. R143 pulled the call light string and the string pulled R105's string from R105's reach. The call light system was not activated when R143 pulled the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light was accessible and within reach in 4th floor shower room. This failure has the potential to affect all 70 residents residing on the 4th floor. Findings include: Facility document titled, (Facility) Daily Census 7/7/2024 shows a total number of 70 residents residing on the 4th floor. On 7/8/24 at 11:53am, R21 stated, A few days ago I (R21) was left in the shower and unable to reach the call light because the call light is too far and also did not have a string to pull. R21 stated, I (R21) had to reach for my bag that had my phone in it and I (R21) called V39 (R21's family member). V39 then called the nurse's station to tell them to get someone to help me. R21's Face Sheet documents, in part, diagnoses of multiple sclerosis, paraplegia, Diabetes Mellitus Type II, hypertension and anxiety disorder. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) for identified change in a resident's psychiatric diagnosis. This failure affected 1 resident (R61) in a sample of 62. Findings include: R61's admission record documents in part the following: chronic obstructive pulmonary disease, heart failure, schizoaffective disorder (onset date 3/22/2023), unspecified mood disorder (onset date 8/25/23), major depressive disorder (onset 2/9/2022). On 7/9/2024, record review of R61's electronic medical record did not indicate that a level I PASRR was completed for R61. On 7/10/2024, record review of R61's electronic medical record noted a level I PASRR was completed on 7/9/2024 for R61, determination: review for level II onsite, suspected mental health disability. On 7/10/2024 at 2:59 PM, V38 (Social Services Consultant) stated that R61's level I PASRR was completed on 7/9/2024 as R61 is due for a quarterly assessment and because schizoaffective disorder was identified on 3/22/23. Surveyor inquired why the PASSR was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide daily activity programming and activity programming as identified on the resident's care plan. This failure affects 3 residents (R11, R99, R40) in a sample of 62. Findings include: R11's admission record documents in part the following diagnosis: encephalopathy, heart failure, dysphagia, dementia without behavioral disturbance, peripheral vascular disease, functional quadriplegia, and failure to thrive. R11's Minimum Data Set, dated [DATE], documents in part a brief interview of mental status (BIMS) score of 3, indicating R11 has severe cognitive impairment and is dependent of facility staff for activities of daily living (eating, dressing, toileting, bathing, transferring). R11's care plan, dated 3/20/2018, documents in part the following, (R11)'s preferences will be provided as applicable. Preference for having the television on while in (R11's) room . 1:1 programming will be provided in order to supplicate similar meaningful…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that an adaptive device (splint/hand roll) was in place for one resident (R52) with bilateral hand contractures. This failure affected one resident in the sample of 62 reviewed for limited mobility. Findings include: On 07/08/24 at 11:06 am, R52 was observed in bed not alert and unable to communicate. Surveyor observed R52 with bilateral hand contractures and without the use of splints or hand rolls in place in R52's hand contractures. On 07/09/24 at 9:50 am, R52 was observed in bed not alert and unable to communicate. Surveyor observed R52 again without the use of splints or hand rolls in place to R52's bilateral hand contractures. On 07/09/24 at 9:56 am, Surveyor brought this observation to V31 (Restorative Aide) and V31 stated, I (V31) was off yesterday and there was no restorative aide in the facility, so no residents splints were applied. I (V31) have been looking for R52's splints all day and I (V31) can't find it. V31 then explained that V31 usually applies R52 splint at 7:00 am and that R52…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a resident with accurate liquid consistency fluid and nutritional supplement on the lunch meal tray from the resident's mechanically altered diet order which affected one resident (R69) when reviewed for nutrition in the total sample of 62 residents. Findings include: On 7/8/24 at 12:45 pm, R69 observed in R69's room in the bed with a stoma in R69's anterior neck, open to air, from a decannulated tracheostomy appliance. V7 (Agency Certified Nursing Assistant, CNA) delivered R69's lunch meal tray from the meal cart in the dining room, and V7 observed setting up R69's lunch tray on the table positioned over R69's lap. R69 picks up the utensils from the tray and begins to feed self the puree textured food from the plate with R69's left hand, and V7 exits R69's room. This surveyor observed a red cup with lemonade (thin liquid) with no lid; a prepackaged and sealed cup of thickened water with lemon (labeled 4 fluid ounces with pink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to properly date the oxygen tubing, failed to ensure the humidifier bottle is not empty, failed to ensure that a backup tracheostomy appliance was at the bedside of a resident with a tracheostomy connected to a ventilator and failed to ensure that for a resident receiving humidified oxygen via a tracheostomy collar tubing, the nebulizer extender port was closed when a nebulizer medication was not infusing. These failures affected three residents (R109, R139 and R141) reviewed for oxygen care and equipment, in a total sample size of 62 residents. Findings include: 1) R139 admission diagnoses includes but not limited to, acute and chronic respiratory failure with hypoxia, asthma, dependence of supplemental oxygen, and congestive heart failure. R139's Brief Interview of Mental Status (BIMS) dated 6/5/24 shows a score of 14 which indicates that R139 is cognitively intact. R139's MDS (Minimum Data Set) Section O. dated 6/5/2024 documents, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to label medication for one resident (R511) and discard expired medications for one resident (R127). This failure affected two residents receiving medications on the 2nd floor. Findings include: On 7/98/2024 at 11:19am surveyor observed R511's canister of Fluticasone 50mcg (micrograms) with no open or use by date on it. Surveyor also observed R127's Albuterol inhaler 108mcg that was ordered on 7/19/2023 with a worn label with no open or used by date. On 7/09/2024 at 11:39am V4 (Licensed Practical Nurse-LPN) stated nose spray canisters and inhalers should be labeled with the date it was opened and the date it expires or use by date. On 7/10/2024 at 1:28pm V2 (Director of Nursing) stated expired and medications with worn labels should be discarded because of possible contamination and may no longer be effective and the purpose of labeling the medication is to know when it was opened and when to discard the medication. Dated policy (01/2022) titled Storage/Labeling/Packaging of Medications documents, in part,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide a thermometer for one resident (R23) refrigerator. This failure affected one resident in the sample of 62 residents. Findings include: R23 has a diagnosis which includes but not limited cardiomegaly, hypertensive heart disease with heart failure, atrial fibrillation, iron deficiency, and constipation. R23's Brief Interview for Mental Status (BIMS) dated 04/19/24 documents that R23 has a BIMS score of 15 which indicates that R15 is cognitively intact. On 07/08/24 at 11:32 am, Surveyor observed R23 in bed alert and awake with R23's personal room refrigerator missing a refrigerator temperature log sheet. R23 states that R23 sees the housekeeping staff checks R23's refrigerator twice a week. On 07/09/24 at 9:20 am, V29 (Housekeeping Supervisor) stated that the housekeeping department is not responsible for checking and logging the residents personal refrigerator temperatures. V29 stated that V29 and housekeeping staff is only responsible for cleaning the residents refrigerators daily. V29 stated that V9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain guardianship for a resident with no documented representative and could place the resident at risk of receiving services without a representative's consent. This failure affected 1 (R4) resident reviewed for guardianship and resident rights in a sample of 7. Findings Include: R4 was admitted to the facility on [DATE]. R4 has diagnosis not limited to Persistent Vegetative State, Dependence on Supplemental Oxygen, Tracheostomy, Dysphagia, Nontraumatic Subdural Hemorrhage, Encephalopathy, Essential (Primary) Hypertension, Gastrostomy, Chronic Respiratory Failure with Hypoxia, Peripheral Vascular Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. R4's MDS (Minimum Data Set) Section C - Cognitive Patterns document in part: Resident sis rarely/never understood. Cognitive Skills for Daily Decision Making: 3. Severely Impaired - never/rarely made decisions. R4 Electronic Medical Record documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to follow their wound prevention policy by failing to ensure pressure ulcer prevention measures were implemented and failing to place interventions in place timely for one of three residents (R1) reviewed for pressure ulcers, Findings include, R1's clinical record indicate in part: R1 was admitted on [DATE] with medical diagnosis include but not limited to chronic kidney disease, stage 4 (severe), type 2 diabetes mellitus, essential (primary) hypertension, heart failure, diverticulitis of intestine, weakness, polyarthritis, myalgia, obstructive and reflux uropathy, major depressive disorder, anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, long term (current) use of insulin, personal history of transient ischemic attack (tia), and cerebral infarction. R1's Initial Nursing assessment dated [DATE]. Completed, signed, and locked on 2/19/24: -Left gluteal fold excoriation [No physician orders noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and document review the facility failed to provide a safe and functional environment for one ( R1) of eight residents reviewed for safe and functional environment. Findings include: On 5/29/24 at 11:00 AM R1s room was observed with a bedside cabinet missing the top drawer front. Sharp screws and nails were sticking out of the cabinet. A second and third cabinet in the room was observed with the drawers hanging from the [NAME] drawer slides. The drawers could not be opened easily and without falling from the cabinet when opened. On 5/30/24 at 2:10PM V17 ( Maintenance Director) stated I am aware of the broken cabinets in R1s room. I will remove the hazardous cabinets and there are new cabinets on order to replace . I am currently going through the entire building to find any resident furniture that needs replacement . Facility policy titled Maintenance Policy And Procedure , Resident Areas Safety Audit , Revised 3/14 states A. Policy Building manager will be responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their resident/family notice regarding room/roommate change policy and provide written notices, including the reason for the room change, for three (R3, R9, R10) out of three residents reviewed for room change notification. Findings include: On 05/08/2024 at 2:05 PM, R10 stated that she was not given a reason as to why she had a room transfer on her previous room change. On 8/5/2024 at 1:58 PM, V23 (R9's son) states that he is not sure if he was notified of R9's room change. V23 states that he called the other day and is aware that R9 is in her current room because V23 states that he couldn't remember, or he might have missed the call. On 05/08/24 at 3:28pm, V3 (Registered Nurse/Infection Control/Assistant Director of Nursing) states that there is no written notification form for R3 due to forgetting to do it. V3 states that the nurse on duty is supposed to be doing the written notification form. R10's MDS/Minimum Data Set, dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide scheduled showers for a resident who is dependent with Activities of Daily Living/ADL care. This failure affects one (R4) resident out of three residents reviewed for ADL care. Findings include: R4's Facesheet documents that R4 was admitted to the facility on [DATE] with diagnosis not limited to: Hypertensive chronic kidney disease, klebsiella pnuemoniae, encounter for attention to tracheostomy, encounter for attention to gastrostomy, encephalopathy, dysphagia following cerebral infarction, hyperlipidemia, other seizures, and non-traumatic intracerebral hemorrhage. R4's MDS/Minimum Data Set, dated [DATE] documents that R4 does not score on the BIMS/Brief Interview for Mental Status. R4's MDS documents that R4 has memory problems and is severely impaired with daily decision making. R4 has bilateral upper and lower extremity impairment and R4 is dependent with ADL/Activities of Daily Living care. R4 is incontinent of bowel and has a condom…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the presence of a pressure ulcer and failed to provide necessary treatment and services to promote healing of an existing pressure ulcer for one (R4) out of three residents reviewed for pressure ulcers. These failures resulted in R4 developing an open wound on the back of R4's neck while residing in the facility. Findings Include: On 05/07/2024 at 12:18PM, V8 (Respiratory Therapist) located inside of R4's room performing suctioning of R4's airway/tracheostomy. Surveyor inquires to V8 about any known wounds on the back of R4's neck. V8 states R4 does not have any wounds on the back of R4's neck. V8 states the respiratory staff is responsible for changing R4's tracheostomy ties/trach ties approximately every 2 days. V8 states whenever the respiratory staff changes R4's trach ties, they observe R4's skin status. V8 states he has not noticed any wounds on the back of R4's neck whenever V8 changes R4's trach ties and states R4 does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to immediately notify the physician of a critical lab value for one (R3) of three residents reviewed for improper nursing care. Findings include: R3's physician order summary documents order Repeat CBC and CMP on Thursday 4/25/2024 one time only for follow-up labs for 1 day. Lab Results Report, 4/25/2024 14:28 documents in part: collection date 4/25/2024 13:18, received date 4/25/1014 13:18, reported date 4/25/2024 14:28, called to on 4/25/2024 at 16:02 by (lab), BUN result of 92 printed in red text. Report legend reads Report contains critical results (results with red text). R3 nurse progress note dated 4/27/2024 at 18:38(6:30PM) reads in part: Comp. Metabolic Panel (comprehensive metabolic panel)/CBC W. Diff & Plat (complete blood count with differential and platelet) relayed to Dr. #####, due to abnormal critical labs. Order is to send resident to the hospital for critical care treatment. On 5/8/24 at 2:25 PM, V2 (Director of Nursing) stated the nurse should review the labs and notify the physician of abnormal labs within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to follow its policy on indwelling urinary catheter care for one (R1) of three residents reviewed. This deficiency has the potential for R1 to develop catheter-associated urinary tract infections. Findings include: R1s current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to: encephalopathy, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, epilepsy, unspecified, not intractable, without status epilepticus, and R1's MDS (Minimum Data Set) dated [DATE], is not scored and documents R1 has memory problem and his cognitive skills for daily Decision making is severely impacted. R1's MDS section GG-Functional Abilities and Goals, document R1 is dependent on staff for all ADL (Activities of Daily Living) care, and R1's MDS section H -Bladder and Bowel documents R1 has an Indwelling catheter and is always incontinent of bowel. On 03/31/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their change of condition policy for one of three residents (R3), reviewed for change of condition. Findings include: R3's progress note of 2/28/2024 17:06 Nurses Note Text: Resident sent back to the unit due to infiltration with dialysis access, some lethargy and weakness noted MD at bedside orders to send resident to (Hospital) for evaluation for dialysis access and deterioration on ability level. MD requesting CT scan report given to (Hospital). R3's progress note of 2/28/2024 22:52 Lab Progress Note Text: Resident is in Hospital R3's progress note of 2/29/2024 05:19 Nurses Note Text: Spoke to RN at (Hospital ER). Resident is still being evaluated. R3's progress note of 3/1/2024 05:02 Nurses Note Text: Resident admitted to (Hospital) RE: eval (evaluation)/treat dialysis access, & lethargy. No documentation regarding notification of R3's responsible party regarding R3's change in condition and transfer to hospital is found in R3's medical record (progress notes). 3.14.2024 at 3:32 PM, V13 (LPN-Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide incontinence care for three residents (R5, R6 and R7) who were unable to carry out ADLs. This failure affects three residents (R5, R6 and R7) out of 5 residents reviewed. Findings include: On 12/19/23 at 12:08 pm R7 observed in her bed, Semi-Fowlers position, alert, oriented to self, place, time and situation. R7 says this morning she put the call light around 9 am and asked to be changed. R7 says the Certified Nursing Assistant (CNA) said she would come back, but she didn't. R7 says she is soiled and says, it's just wrong. R7 has a urinary catheter. The CNA was identified as V17. On 12/19/2023 at 12:17pm, surveyor walked into R5's room and noted V2 (Agency Certified Nursing Assistant) at R5's bedside about to begin R5's activity of daily living (ADL) care. Surveyor observed R5, a non-verbal bed bound resident with a tracheostomy, to be wet and soiled with a loose bowel movement. Surveyor observed R5's sheet to be soaked with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to clean the gastrostomy tube (g-tube) site for 3 residents (R4, R5, R6) out of 3 residents reviewed for g-tube care in a sample of 11 residents and failed to change a soiled sacral wound dressing for R4. Findings include: R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: multiple sclerosis, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, encounter for attention to tracheostomy, encounter for attention to ileostomy, other pulmonary embolism without acute cor pulmonale, unspecified severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4. R4's care plan (dated 11/14/2023) documents that R4 has an actual alteration in skin integrity r/t pressure ulcer to sacral, right buttock, R heel, R lat. ankle; non pressure ulcers to R lat. foot, R lat. foot distal and toes, L thigh and R leg; irritation on to peri-stoma. R4's care plan documents that R4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide dependent residents with weekly showers for two residents (R33 and R82), did not provide shaving for two residents (R112 and R41), and did not provide nail care for one resident (R112). This failure has affected four residents from a sample of 56 that were reviewed ADL (Activities of Daily Living) care. Findings include: R33 is [AGE] year old with diagnosis including but not limited to: Limb Girdle Muscular Dystrophy Protein- Calorie Malnutrition, Malaise, Chronic Pain Syndrome, Scoliosis and Depression. R33's BIMs (Brief Interview for Mental Status) documents a score of 14, which indicates cognitively intact. R33's MDS (Minimum Data Set) Functional Status documents total dependence with personal hygiene. On 6/5/2023 at 11:15 Surveyor observed R33 lying in bed, she was on her cellular device, on a conference call. R33's room had an odor of urine and feces. R33 was the only resident assigned to the room. On 6/5/23 at 11:15, R33…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based observation, interview and record review the facility failed to adhere to pressure ulcer prevention measures (turning and repositioning (R30), layering (R34 and R87) and correct low air loss mattress setting for 3 residents (R30, R76, and R82). These failures affected 5 residents (R30, R34, R76, R82 and R87) out of a sample of 56. Findings: R76 has a diagnosis of but not limited to Chronic Embolism and Thrombosis unspecified Deep Veins of Lower Extremities, Neuromuscular Dysfunction of Bladder, Chronic Respiratory failure and Dysphagia following Cerebral Infarction. R82 has a Brief Interview of Mental Status of 15. R76's Care plan dated 5/29/2023 documents that R76's has potential for alteration in skin integrity and one of the interventions is Pressure redistribution support (low air) in bed. On 6/05/2023 at 11:17am surveyor observed R76's low air loss mattress set at alternating pressure at 280lbs. On 6/07/2023 at about 4:15pm surveyor reviewed R76's weight and vitals that document on 6/01/2023 R76's weight was 173.5lbs and R82's weight taken on 6/01/2023 was 245.3. R82 has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure a container of Sani-Cloth Germicidal Disposable Wipes was not left inside a resident's room in an effort to keep the resident's environment as free of accident hazards as is possible. This failure affected R141 reviewed for safe environment and has the potential to affect all 30 residents in the second floor. Findings include: On 06/05/23 at 11:35 am, there was a container of Sani-Cloth Germicidal Disposable Wipes in R141's room. The container has about a quarter of Sani-cloth wipes. R141 stated one of the cleaning people left it in his (R141) room. On 06/05/2023 at 11:37am, V4 (Building Manager/Maintenance Director) stated the 'wipes' are not supposed to be in the resident's room because sometimes residents get confused and think they can wipe their hands with it. On 06/07/2023 at 10:36am, V2 (Interim Director of Nursing) stated we (facility) are not supposed to leave the Sani wipes in the resident's room. The resident may use it as a hygiene wipe and the resident may get skin irritation. It can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to label and date oxygen equipment (tubing and humidifier bottle), failed to contain oxygen tubing, and failed to ensure physician order was obtained for oxygen. These failures affected four residents (R7, R23, R66, and R159) reviewed for oxygen in a total sample of 56 residents. Findings include: R23 has an admission diagnosis of but not limited to chronic obstructive pulmonary disease, bronchitis, epilepsy, anxiety, and dependence on supplemental oxygen. R23's Brief Interview for Mental Status (BIMS) dated 4/21/23 score is 99. On 6/5/23 at 10:20 am, observed R23 lying in bed receiving oxygen through an oxygen nasal tube at 5 1/2 liters. R23's humidifier bottle was sitting on a small suitcase for support and undated. R23 stated the humidifier bottle is on my suitcase because I need to support the bottle, it will pull on my tubing if it's not on the suitcase. On 6/5/23 at 10:40 am, surveyor inquired to V37 RN (Registered Nurse), if a date was on the humidifier bottle and why it is on R23's suitcase. V37 stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that the controlled substances accountability form was signed off simultaneously by the outgoing and incoming nurse at the start of the shift acknowledging that the count being passed on to the next nurse was correct. This failure has the potential to affect all 7 residents receiving a controlled substance from the 3 [NAME] Team 1 medication cart. Findings include: On 6/6/23 at 11:15 AM, during review of the Shift Count Documentation log for controlled substances on the 3 [NAME] Team 1 medication cart, the box for the 1st shift for 6/6/23 was noted to be unsigned. V34 (LPN/Licensed Practical Nurse) stated, I (V34) should have signed right here. V34 affirmed that the log should be signed at the change of the shift after counting the narcotics with the outgoing nurse to show that I (V34) took over from her. On 6/7/23 at 4:36 PM, V2 (Interim DON/Director of Nursing) stated that purpose of the narcotic accountability log is to show that they did the narcotic count at the beginning of their shift and that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to label eye drops with an open and discard date for 4 residents (R59, R62, R111 and R135), failed to ensure a medication for one resident (R52) was labeled with a pharmacy label or kept in a pharmacy-labeled bag, and failed to ensure personal food items were not stored in the freezer portion of the medication refrigerator. These failures affected R52, R59, R62, R111 and R135 and have the potential to affect all 70 residents residing on the 3rd floor. Findings include: The 6/4/23 Daily Census Report lists 14 total residents for 3 [NAME] Team 1, 18 total residents for 3 [NAME] Team 2, and 38 total residents for the Vent Unit located on the 3rd floor. On 6/6/23 at 10:56 AM, the surveyor along with V34 (LPN/Licensed Practical Nurse) checked the medication cart serving rooms 309-316 for appropriate storage and labeling of medications. The following eye drops were noted to have no open or discard date: -R59's Refresh Tears with a dispense date of 5/18/23. -R62's Refresh Tears with a dispense date of 5/30/23. -R111's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure staff donned appropriate PPE (personal protective equipment) prior to entering an isolation room, failed to ensure staff performed appropriate hand hygiene prior to handling food items and plate covers, and failed to ensure plate covers were not touching staff's uniform. These failures affect R99 and have the potential to affect all 30 residents on 2nd floor. Findings include: On 06/05/23 at 12:13 PM, V12 (Dietary Aide) plugged in the steam table and, without performing hand hygiene, grabbed the tray of salad and bread at the bottom shelf of the steam table and placed the tray on a table that held the soup bowls, beverages, and plate covers. On 06/05/2023 at 12:15pm, this observation was pointed out to V12 with V42 (Housekeeping) translating for this surveyor. V12 stated she (V12) did not perform hand hygiene prior to touching the tray of salad and bread. On 06/05/23 at 12:25pm, V13 (Speech Language Pathology) was placing cover…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that the call light system is maintained and functioning properly on the 4th floor to ensure a timely response to the resident's call for assistance. This failure affected two residents (R23 and R73) and has the potential to affect all 69 residents residing on the 4th floor. Findings include: The 6/4/23 Daily Census documents 33 total residents on the 4th Floor Team 1 and 36 total residents on the 4th floor Team 2. On 6/5/23 at 11:56 AM, the surveyor observed the light above R73's room to be on while standing in the hallway near the nurse's station. No ringing could be heard to indicate that the call light was on. The light on the call light panel for R73's room was observed on. V21 (Social Services Director), V23 (admission Director) and V18 (LPN/Licensed Practical Nurse) were observed sitting at the nursing station with their backs to the panel seemingly unaware that a call light was on. On 6/5/23 at 12:06 PM, V20 (RA/Resident Aide) was seen entering R73's room and the call light was turned off. V20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a code status was documented for one of seven residents (R97) reviewed for Advanced Directives. Findings include: R97 is [AGE] year old with diagnosis including but not limited to: Encephalopathy, Chronic Respiratory Failure, Cerebral Palsy, Injury of Head, Traumatic Fracture, and Quadriplegia. On [DATE] Surveyor observed R97's admission Record without code status documented. On [DATE], Surveyor inquired about R97's code status. On [DATE] at 11:53 am, V18 (agency Licensed Practical Nurse) said I'm not sure. The code status does not show here on the computer. Surveyor asked if there was a code status book located on the unit in the event of an emergency or a code? On [DATE] at 11:53 am, V18 said, I'm not sure if there is a code book on the unit, I have never seen one though. On [DATE] at 4:30 pm, V2 (Director of Nursing) said, Social Services is responsible for updating the code status for residents. The only way the nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain the confidentiality of resident's personal information and failed to ensure that a resident's personal information was properly discarded after discharge. These failures affected 2 residents (R30, R167) reviewed for confidentiality of records in the total sample of 56 residents. Findings include: On 6/05/23 at 10:50 AM, the surveyor observed a standard size piece of paper pinned to the communication board above R128's headboard. The paper had R167's name typed on it and a hand-written message, Attn: (Attention) Please place lotion inside top drawer. (Lidocaine) on her feet. Gently. Thank you. God Bless. Mention the name (name provided) (son) so she may be more cooperative. At 10:57 AM, this observation was brought to the attention of V18 (LPN/Licensed Practical Nurse) who stated, That's not her (R128's) name. At 10:59 AM, V18 took the paper down and brought it out to show V19 (RN/Registered Nurse) who stated, I'm not sure why it was up there. On 6/5/23 at 1:21 PM, V19 confirmed that R167 has been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to ensure an order for the discontinuation of contact isolation was received in 48 hours after the last dose of antibiotic was administered. These failures affect 1 (R152) resident reviewed for transmission-based precaution in the total sample of 56 residents. Findings include: On 06/05/23 at 11:00 am, there was a 'Contact Precautions' sign posted on the right side of R152's doorway. On 06/05/2023 at 11:02am, V7 (Travel LPN) stated she (R152) came from the hospital. She (R152) was placed on contact isolation when she (R152) was admitted . I (V7) am not sure about the stop date. On 06/05/23 at 11:57 am, V3 (Infection Preventionist/ADON) stated the contact isolation should have been discontinued after treatment. If the resident is not having diarrhea after 48 hours of the last dose of the antibiotic, we can discontinue the isolation. We (facility) should get the discontinuation of the isolation order from the doctor. The last dose of Vanco (Vancomycin) was given on 4/24 and contact isolation should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow physician's orders and apply a hand splint for one resident (R31) with limited range of motion (ROM) and failed to provide documentation related to application or refusal of the splint. These failures affected 1 (R31) resident of 7 residents reviewed for assistive devices in the total sample of 56 residents. Findings include: On 6/5/23 at 10:55 AM, R31 was observed lying in bed trying to straighten out the fingers in her (R31) left hand which appeared contracted. This observation was brought to the attention of V18 (LPN/Licensed Practical Nurse) who stated that R31 does not have an order for hand splint. V18 added, Yeah it would be beneficial. V18 acknowledged that R31 is not able to move her (R31) fingers in her left hand on her own. V18 stated that a splint is used, To prevent contraction. On 6/5/23 a 11:04 AM, V23 (admission Director) assisted this surveyor with translation since R31 speaks mainly Spanish. V23 translated that R31 stated that she (R31) will let staff put a splint on her (R31) and that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.